Regional Blocks in Outpatient Surgery

Roy Greengrass M.D. F.R.C.P.Professor of Anesthesiology

Mayo Clinic Jacksonville

Your Personal Case Scenario

• Your only son graduates from MIT in 2 days. In your excitement getting everything ready to travel for this important event you trip on a rug and fracture your arm requiring surgery. Dr. Evans recommends interscalene catheter and propofol sedation for the procedure with interscalene analgesia postoperatively. Unfortunately your hospital has no one with expertise in this procedure. What do you do?

Disclosure

• I have no relevant financial relationships with any commercial interests related to the content of this activity.

Learning Objective

• List the different kinds of peripheral nerve blocks, the choice of local anesthetics, and their role in outpatient surgery and post op pain management.

Why not Gas and Opioids for Everyone?

General Anesthesia for Ambulatory Surgery - Advantages

• Easy to initiate

• Minimal assistance required

General Anesthesia for Ambulatory Surgery - Disadvantages

• Ubiquitous nausea, vomiting

• Postoperative pain usually mandates opioids which have well documented side effects

Regional Anesthesia-Advantages

• Evidence-based medicine suggests that multimodal anesthesia with regional anesthesia as the primary modality results in advantages of superior analgesia,earlier discharge,enhanced convalescence and better patient satisfaction compared with more traditional approaches.

Regional Anesthesia for Ambulatory Surgery -Disadvantages

• Skill level required to perform efficiently

• Often requires assistance

• Concern for side effects

Regional Block-Methods to Enhance Efficacy

• A dedicated pre-operative area with appropriate equipment is essential for performance of blocks –do not perform blocks in the OR under “surgical” time.

• Early performance of blocks allows for assessment of efficacy with the opportunity to redo/rescue block if necessary.

Ambulatory Surgery-Nausea and Vomiting

• By far the most important determinant of prolonged PACU stay

• More debilitating than pain-patient surveys

• Polypharmacy with antiemetics often ineffective

• Recurrence of symptoms after discharge

Nausea and Vomiting

• 60% of all breast procedures- even “minor” (includes plastics)

• Multifactorial– General anesthetics– Opioids– ?reflexes

Paravertebral Block

• A somatic block of the mixed nerve soon after exiting the intervertebral foramina

• Allows profound anesthesia/analgesia without the associated effects of centralneuraxial anesthesia

Fast Tracking with Nerve Blocks for Breast and Hernia Surgery

Roy A. Greengrass, M.D.

Associate Professor of Anesthesiology

Mayo Clinic, Jacksonville, FL

Does Regional Anesthesia Impact Pain?

Does Continuous Peripheral Nerve Block Provide Superior Pain Control to

Opioids? A Meta-AnalysisRichman Anes Analg Jan/06

• 19 randomized clinical trials enrolling 603 patients

• At all times and for all catheter locations CRA provided superior analgesia

• Opioid related side effects were significantly reduced using CRA techniques

“Almost all cases of hernia, with the possible exception of those in young

children, could undoubtedly be subjected to the radical operation

under local anesthesia”H. Cushing Annals of Surgery 1900

Postherniorrhaphy Urinary Retention-Effect of Local,Regional,and General Anesthesia

Jensen Reg Anes Pain Manag Nov/Dec 2002

• Medline search 1996-2001 “Urinary Retention” not delay in passing urine

• 70 non-randomized,2 randomized studies• “Regional”=central neuraxial• General = 3%(11471 pt), Central =2.42%(6191),Local =

0.37%(8991)• Dispels the myth of less UR with GA (GA interferes with

the Autonomic Nervous System)• Opioids cause urinary retention ( eg morphine relaxes the

detrusor while maintaining normal sphincter tone)

C.R.A. Applications: Orthopaedic Surgery

Upper Extremity

• Total elbows- CPM

• Total shoulders

• Trauma

Popliteal Block

Hadžić A, Vloka JD: Peripheral Nerve Blocks. Principles and Practice. McGraw-Hill, New York, 2004, Figure 22-19, p 296.

Continuous Interscalene Analgesia

• How many of you routinely send patients home with interscalene catheters?

• How many of you routinely insert IS catheters?

• Why not single shot blocks?

Continuous Interscalene Analgesia-Indications

• Surgical procedures involving the shoulder, arm, lateral forearm and lateral hand

Palliative analgesia in patients with metastatic disease

• Sympathectomy for vascular reconstructive surgery

Ambulatory Continuous Interscalene Nerve Blocks Decrease the Time to

Discharge Readiness after Total Shoulder Arthroplasty

Ilfeld Anesthesiology Nov/06

• Discharge criteria ( adequate analgesia, independence from intravenous analgesics, tolerance to 50% of shoulder motion targets) achieved significantly earlier in patients receiving continuous perineural 0.2% ropivacaine vs saline controls

• Essentially impossible to allow 23 hour discharge unless CRA is present ( Duke and Mayo experience)

Analgesic Effectiveness of a Continuous Versus Single Injection

Interscalene Block for Minor Arthroscopic Shoulder Surgery

Fredrickson Reg Anes Pain Management Jan-Feb/10

• Procedures including subacromial decompression, excision lateral clavicle, stabilization procedures

• Significantly less pain and enhanced range of motion versus single shot blocks

• Ubiquitous use of opioids in patients with chronic pain makes “minor” surgery a misnomer

Interscalene Block

Applications C.R.A: Orthopaedic Surgery

Lower Extremity

• ACL reconstructions

• Total ankles, triple arthrodesis

• Extensive tumor surgery

• Total knees

Popliteal Block

Hadžić A, Vloka JD: Peripheral Nerve Blocks. Principles and Practice. McGraw-Hill, New York, 2004, Figure 22-19, p 296.

Caveats to Safe Practice of Regional Anesthesia

• Don’t do blocks with patients under general anesthesia

• Inject 1ml test dose – if patient complains of severe pain don’t “reposition” the needle-remove it-and abandon the block

• Author avoids epinephrine• CRA may be through needle or catheter-if via

catheter dilate space first (DW-can still stimulate)

CRA-Home Catheter Service

• Disposable Pump

• Removal by patient/care giver

• Anesthesiology consultation available 24/7

Are There Other Benefits Using Regional Anesthesia?

Preincisional Paravertebral Block Reduces the Prevalence of Chronic

Pain After Breast SurgeryKairaluoma Anes Analg Sept 2006

• PVB vs GA 1 year followup: Prevalence of pain PVB<< GA ( P= 0.003)

• Dynamic pain PVB<< GA ( P= 0.003)

• Pain at Rest PVB<<GA (P= 0.01)

• ? Deafferentiation + enhanced blood flow

• (seen also with post-thoracotomy pain)

Can Anesthetic Technique for Primary Breast Cancer Affect

Recurrence or Metastasis?Aristomenis Anesthesiology Oct 2006

• GA vs PVB

• 32 month followup

• Recurrence and met free survival 1 year 94% PVB vs 82% GA/opioid

CRA-Significant Cost Savings

• Duke – TSA-formerly 3 days-23 hour with IS catheter

• Mayo – TAA –formerly 3 days – 23 hour with Pop catheter

Your Case Scenarios

• You choose the “gas and oid” approach, experience severe post-op pain needing excessive doses of PCA analgesics, and have nausea and vomiting related to the opioids. You are advised not to travel due to your problems and cancel your flight

• You choose the block approach, are discharged from PACU with a CRA device , and fly out to enjoy your son’s honor